Homicidal ideation ICD 10

Homicidal ideation ICD 10 codes and categories are used by therapists for the rare person who might follow through on killing someone.

Summary

• The majority of individuals have had at least one homicidal thought, but only a very small number are at risk of acting on it. Therapists must assess seriousness through intent, planning, means, and protective factors.

• ICD-10 recognizes homicidal ideation as a symptom, not a disorder. The appropriate code is R45.850, distinguishing it from codes related to actual assault or homicide attempts. Enrolling in an insurance billing course for therapists can help providers enhance their knowledge of codes.

• Therapists evaluate homicidal ideation similarly to suicide risk, considering history, current intent, and access to weapons. Tools like the Sheehan-Homicidality Tracking Scale (S-HTS) can help structure this evaluation.

• Therapists must balance confidentiality with the duty to warn when credible threats exist, thoroughly documenting all assessments and actions to protect both clients and potential victims.

• By leveraging an EHR like TheraPlatform, therapists can maintain accurate records should they treat a client with this condition.

It is estimated that 76 percent of women and 91 percent of men reported having at least one homicidal thought in their lifetime. For most, this is just a fantasy that they will never complete. The difficulty is when therapists encounter someone who may follow through on it.

Let's explore the challenges of treating the client with homicidal ideation, understanding the homicidal ideation ICD 10 code, and concerns with assessment and treatment while balancing ethical and legal obligations.

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What is homicidal ideation?

Put simply, homicidal ideation is having thoughts about killing someone else. For our purposes, it is more realistically defined as having serious thoughts about committing homicide.

More often than not, people who exhibit homicidal ideation display a related mental health problem, such as psychotic symptoms, mood disorders, suicidal ideation, substance abuse, and personality disorders.

Homicidal Ideation ICD 10 Code

Homicidal ideation is not considered a disorder in the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Instead, it is recognized as a symptom, part of "symptoms and signs involving cognition, perception, emotional state, and behavior."

Here are the relevant homicidal ideation ICD 10 categories:

• The homicidal ideation ICD 10 billing code is R45.850.

• This is not to be confused with code Y09, which is technically an "assault by unspecified means," but is also the general code used for an attempted homicide. This is an important distinction because most people who have homicidal ideation will not attempt the act itself.

• A completed homicide is categorized according to the type of method used, using an assortment of X and Y codes.

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Assessment of homicidal ideation

Assessment for homicidal ideation involves evaluating similar factors to suicidal behavior:

• A history of violent and impulsive behavior is a major indicator. Has the user had assaultive behavior or attempts at homicide in the past?

• Intent. Does the client say that they currently want to kill someone else?

• Plan. Does the individual have a plan for committing homicide? Is it detailed enough to show that they have thought it through?

• Means. Do they have the means to carry out their plan? For example, if the client says they want to shoot someone, do they have access to a gun?

• Protective factors. Does the client have anything or anyone in their life that would stop them from carrying out a homicide? For instance, maybe they have a young child that they need to care for and don't want to abandon.

• Substance abuse is often associated with homicidal behavior. People are more likely to be impulsive and aggressive when on drugs or alcohol.
  • Although weighing the factors above is a subjective analysis, clinicians can use this tool to guide them when measuring the risk of homicide.
  • For a more structured homicidal ideation screening measure, clinicians can check out the Sheehan-Homicidality Tracking Scale (S-HTS).

Intervention strategies for homicidal ideation

The following are several interventions for homicidal ideation, depending on the level of risk:

• For lower-risk clients, you want to focus on helping them cope with immediate stressors that are contributing to their homicidal thoughts.

For example, addressing a highly conflictual divorce situation where the client has expressed homicidal ideation towards their spouse. Cognitive-behavioral therapy is a valuable tool for recognizing and changing maladaptive thoughts.

• For medium-risk clients, you want to develop a safety plan. A safety plan will include recognizing warning signs, using coping skills, and connecting with friends, family, and professionals for support.

For obvious reasons, you want to work with the client on creating the safety plan before a crisis occurs. Family members must be contacted (with consent) to serve as support figures.

• For high-risk clients, you will need to have the client receive a psychiatric evaluation to determine if they are safe to remain in the community or if they need inpatient hospitalization.

Ideally, you want the client to agree to go to the hospital with a loved one for an evaluation. If the client refuses, you will have to initiate an involuntary evaluation.

This usually involves calling the police. If you are lucky, your community will have a mobile crisis team that will come to the client.

If not, the police will have to take the client to the hospital against their will. This is the worst-case scenario as it is highly stressful and damages the therapeutic relationship.

• If you have completed an evaluation and are not sure what to do, a good idea is to consult with other therapists, especially experienced supervisors.

As a general rule, when dealing with a possibly homicidal situation, it is always best to err on the side of caution.

Ethical and legal responsibilities for therapists

Homicidal ideation presents a thicket of ethical and legal complications for therapists:

Confidentiality

The therapist must use their best judgment when it comes to confidentiality and homicidal ideation. Homicidal ideation on its own is not a reason to break confidentiality.

However, someone who has intent, a plan, and means to commit homicide must be treated as a significant threat. In that case, the therapist must involve others and provide client information to the authorities and treating professionals.

Breaking confidentiality due to homicidal threats should not come as a surprise to the client. Part of informed consent is telling the client they will have to notify someone if it is determined that the client is a credible threat to harm someone else.

It is also a good idea to regularly reiterate the exclusions to confidentiality when working with a client with homicidal ideation.

Duty to Warn

The "duty to warn" comes into play when dealing with a possibly homicidal client. At its most basic, this means that the therapist must warn the potential victim that their client has made an imminent and serious homicidal threat against them.

However, the therapist's "duty to warn" encompasses the following actions in practical terms:

• Warning the potential victim
• Notifying the police
• Initiating a psychiatric assessment

For most therapists, there is a legal obligation to warn. However, not all states have legal "duty to warn" statutes. States without the law include Maine, North Carolina, North Dakota, and Nevada. However, that doesn't release therapists from their ethical principles.

Even if you practice in a state without a duty to warn statute, therapists still have an ethical obligation to warn a potential victim.

Note: The "duty to warn" is only to be instituted for specific threats against identifiable persons. If a client says they want to kill someone but won't identify anyone specific, then it doesn't apply.

Documentation

Therapists must be extremely careful when documenting a case of homicidal ideation and using homicidal ideation ICD 10 codes.

They need to be clear and detailed when recording what happened during their sessions. In particular, they will want to focus on three areas:

• What methods did they use to assess the client?
• What was the verdict of the evaluation? and
• What interventions were utilized to address the risk?

If a client follows through on their ideation (or the therapist feels they must break confidentiality), the therapist needs to be able to provide the rationale for their decisions and show they took appropriate actions.

Remember, from a legal perspective, if it isn't written down, it didn't happen.

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How EHR and practice management software can save you time with insurance billing for therapists

EHRs with integrated billing software and clearing houses, such as TheraPlatform, offer therapists significant advantages in creating an efficient insurance billing process. The key is minimizing the amount of time dedicated to developing, sending, and tracking medical claims through features such as automation and batching.

What are automation and batching?

• Automation refers to setting up software to perform tasks with limited human interaction.

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Which billing and medical claim tasks can be automated and batched through billing software?

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Utilizing billing software integrated with an EHR and practice management software can make storing and sharing billing and insurance easy and save providers time when it comes to insurance billing for therapists.

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References

Carbone, J. T., Holzer, K. J., Vaughn, M. G., & DeLisi, M. (2020). Homicidal ideation and forensic psychopathology: evidence from the 2016 nationwide emergency department sample (NEDS). Journal of forensic sciences, 65(1), 154-159. https://doi.org/10.1111/1556-4029.14156

Duntley, J. D. (2005). Homicidal ideations. Dissertation, Austin, TX: The University of Texas at Austin. https://repositories.lib.utexas.edu/items/2723a59c-6191-4267-8dae-0dc881334dd3

Hoff, L. A. (1989). People in crisis: Understanding and helping (3rd ed.). Addison-Wesley/Addison Wesley Longman.

Sheehan, I.S. (2013, November 12). Sheehan-homicidality rating scale. https://professorsheehan https://professorsheehan.com/wp-content/uploads/2014/02/sheehan-homicidality-tracking-scale-s-hts-over-the-past-timeframe1.pdf Sun, C. F., Mansuri, Z., Trivedi, C., Vadukapuram, R., & Reddy, A. (2022). Homicidal ideation and psychiatric comorbidities in the inpatient adolescents aged 12-17. Frontiers in psychiatry, 13, 933524. https://doi.org/10.3389/fpsyt.2022.933524

Content provided by TheraPlatform is educational and does not constitute any legal advice.